Laserfiche WebLink
SERVICE REQUEST (SERVREQ) Revised 5/13/93 <br /> =FACILITY # ,'Y,)/; L� RECORD ID # oo ( �� BILLING PARTY Y / \Y <br /> FACILITY NAME y <br /> SITE ADDRESS <br /> CITY V\ (���1 CA ZIP ! FAC # ff <br /> OWNER/OPERATOR �`-/1��C�. BILLING PARTY Y �/� N� <br /> DRA PHONE #1 (7)2 6�p� C 7 - [1�> cQ <br /> ADDRESS , VUR- �'r �� ��� 1 PHONE #Z ( ) <br /> CITY 1y o I e-��1 STATETY, ZIP C �� <br /> �) <br /> APN # Census BOS Dist Location Code City Lode ------ <br /> CONTRACTOR and/or f <br /> SERVICE REQUESTOR ` Y� ��! BILLING PARTY Y / <br /> DBA PHONE #1 <br /> MAILING ADDRESS I oC I7 ( '(' �`-�V �'� � FAX <br /> # ( ) <br /> CITY 1 ! I O C-J. STATE �l—/''� , ZIP <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned owner, operator or agent of same, acknowledge that all site and/or project specific <br /> PHS/EHD hourly charges associated with this facility or activity will be billed to the party identified as the BILLING PARTY on <br /> Page 1 of this form. <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN <br /> JOAQUIN COUNTY Ordinance Codes and Standards, Stated and Federal laws. <br /> APPLICANT'S SIGNATURE l�11V�.� �U#✓"� l� (-� <br /> Date: 060 <br /> Title: DJ <br /> AUTHORIZATION TO RELEASE INFORMATION: In addition to the above, when applicable, 1, the owner, operator or agent of same, of <br /> the property located at the above site address hereby authorize the release of any and all results, geotechnical data and/or <br /> envirormental/site assessment information to SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon as <br /> it is available and at the same time it is provided to me or my representative. <br /> Nature of Service Request: Service Code <br /> // <br /> Assigned to l�-�'f� Employee # ` lr Date <br /> Date Service Completed _/_/_ Further Action Required: Y / N PROGRAM ELEMENT 3'd <br /> Fee Amount Amount Paid Date of Payment Payment Type Receipt # Check # Recvd By <br /> REHS / _/� _/__/_ ACCT _/ UNIT CLK _/_/_ <br />